H0602_MS_MC102PlusRx_04012016 Accepted This information is

H0602_MS_MC102PlusRx_04012016 Accepted This information is

Medicare Covered
Benefit
Rocky Mountain
Plus Plan + Rx (Cost)
You Pay
Monthly Plan Premium
Medical Only
Prescription Drug
(Part D-Optional)
$175.00*
$109.50
Total
Part D Prescription Drug
Benefit (Cost for a 30
day supply)
Level I: Initial Coverage
Limit
$284.50*
* plus you must continue to pay your Medicare Part B premium
No deductible
$3 copay Tier 1
$20 copay Tier 2
$40 copay Tier 3
$60 copay Tier 4
33% coinsurance Tier 5
Level II: Coverage Gap
After $3,310 in total yearly drug costs, Member pays either a $3
copay for Tier 1 and a $20 copay for Tier 2 (for a one month supply) or up
to 58% of the price for generic drugs, whichever is lower and 45% of the
price for brand name drugs until the Member’s out-of-pocket drug costs
reach $4,850.
Level III: Catastrophic
Benefit
After the Member’s out-of-pocket drug costs reach $4,850, they pay
$2.95 copay generic;
$7.40 copay for all other drugs; OR 5% (whichever is higher)
Formulary of Prescription Drugs covered on the Rocky Mountain Plus
Plan +Rx English|Spanish
Mail Order/Retail Rx
Additional RMHP Part D Information and Forms
2.5 copays for 3 month supply
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply.
Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.
This information is available for free in other languages. Please call Customer Service at 888282-1420 (TTY dial 711). Hours are 8am - 8pm, 7 days/week, Oct. 1–Feb.14, and 8am - 8pm,
M-F, Feb.15–Sept.30.
Esta información está disponible gratuitamente en otros idiomas. Por favor llame a la línea de
Atención a Clientes, al 888-282-1420 (TTY marque 711). Horario de 8am - 8pm, 7 días a la
semana, del 1 de octubre al 14 de febrero; y 8am - 8pm, de lunes a viernes, del 15 de febrero
al 30 de septiembre.
RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal.
H0602_MS_MC102PlusRx_04012016 Accepted